Statutory declaration to provide evidence of the character and good standing of the company director/s
Download the statutory declaration (DOCX 579 kB)
Parent company agreement to provide financial support
Statutory declaration to confirm arrangements for financial support where the licensee is being backed by a parent company. This document is not required for an independently funded application
Download the parent company statement statutory declaration (DOC 253 kB)
Statutory declaration, completed by an independent financier or accountant to confirm the financial standing of the licensee
Download the financial standing statutory declaration (DOC 250 kB)
Authority holder's CV and business records
- CV summaries of the company director/s
- Summary of relevant experience in owning/operating a health facility to support current application
- Formal proof of registered office address (eg.: ASIC Current company extract, Copy of Certification of Incorporation or certificate of registration certified by a Justice of the Peace)
Commercial / financial viability
- Evidence of financial stability:
- Sole operator: budget documents (or similar) showing financial stability for the previous 2 financial years
- Company: copy of audited financial statements for previous 2 financial years
- If licensee is being backed by a parent company, you need to provide the parent company's records
- Evidence of financial support, and ability to meet repayments:
- Bank, or other institution, loan arrangements
- Proposed financial plan/operating budget plan, including repayments schedule
- A signed statement from the financier verifying that the entity has the financial capacity to establish and operate the facility for at least two (2) years.
Download the financial standing statutory declaration (DOC 250 kB) This information is forwarded to Equifax for independent review.
This evidence is only required from those applying to operate new facilities.
- High level statement of goals/mission statement/strategic direction, including:
- Overview of the types of CSCF services you wish to offer
- CMBS item number and/or ICD codes for each proposed clinical service
- Any demographic research you may have undertaken into the need for these services in this location
- Proposed organisation chart (including names where known)
Clinical services capability framework (CSCF):
List of services and levels
List of proposed services (for initial approval to build)
Indicate which services and levels you intend to offer.
Clinical services capability framework (CSCF):
Description of services levels
Descriptions of service levels
- Reference the relevant Clinical Services Capability Framework (CSCF) modules—these documents provide details of the minimum requirements to offer each service at a particular level.
- Provide a description for each service, to explain how you meet / intend to meet the requirements.
Please email email@example.com to obtain the necessary self-assessment templates
Description of the area to be licensed
Building plans (for initial approval to build)
- Floor plan for the new/changed facility. We require 2 sets of the plans:
- 1:100 proposed floor plans
- 1:200 proposed floor plans
- Physical address details
If development is occurring in stages highlight different stages on submitted plans.
Description of the area to be licensed for subsequent applications)
This is particularly relevant where a licence only relates to parts of the premises.
- Simple floor plans (eg.: diagram of the evacuation plan for the licensed area.
Management team / staffing details
- Chief executive officer / Manager of the facility – name and copy of current CV
- Nurse in Charge / Director of Nursing – name, copy of current CV and current Australian Health Practitioner Regulation Agency (AHPRA) certificate of registration
- Staffing plan – list intended service providers names and (AHPRA) registration details where applicable. (medical/surgical/allied health/core services and support staff)
Policies and procedures
- copies of the following policies and procedures that must be in place before a facility can operate:
- Medical emergency policy including patient transfer procedures
- Patient admission criteria
- Patient consent procedures
- Patient complaint procedures
- Infection control policy
- Medication management plan
- Quality policy
- Storage and collection of waste, including contaminated waste policy
- Risk management plan
- Credentialling and clinical privileges committee terms of reference and meeting minutes which includes names of members
- Infection Control committee meeting minutes which includes names of members
- Proposed staff roster for each clinical area
- Staff orientation program
- Results of initial water testing taken for Legionella. NB In accordance with the Public Health Act 2005, you are required to develop and implement a water risk management plan. More information
- Name of quality assurance entity, date of registration and proposed date of initial certification.
Download the list of Supporting documentation for an application for a licence to operate (DOCX 125 kB)
Download the list of mental health service specific policies (if applicable) (DOCX 156 kB)
Download the list of alcohol and other drug service specific policies (if applicable) (DOCX 154 kB)
Audit tool – self assessment against the Queensland Private Health Facility Standards
Evidence of compliance with the Queensland Standards is provided via a self-audit checklist.
Where the facility is non-compliant, you should provide the reason, and steps in place to rectify the situation. This is all captured in the checklist.
Download the self-compliance assessment tool (DOCX 547 kB)